Treating Endometriosis: Maximizing Your Outcome

with Charles Koh, M.D., Obstetrics/Gynecology, Columbia St. Mary’s

Posted: Oct. 1, 2004

Women diagnosed with endometriosis often suffer doubly, first from the physical pain and infertility caused by endometriosis and second from the frustration of ineffective treatment. In many cases, conventional therapies – hormonal treatments, cauterization, removal of the ovaries and full hysterectomies – often do not provide lasting relief.

A relatively new procedure, laparoscopic peritoneal resection and radical excision, has shown proven success in removing the endometriosis while maintaining the vitality of a woman’s uterus and ovaries. It provides hope for the estimated 25% of all women who suffer from endometriosis and require treatment. It also means a woman must feel empowered to research the option even if it is not offered by her regular gynecologist.

Charles Koh, M.D., Obstetrics/Gynecology, Columbia St. Mary’s "Treatment should not be removal of the surrogate organ (the uterus), but removal of the endometriosis."

“Hysterectomy is very much a last resort,” explained Grace Janik, M.D., director of reproductive endocrinology at Columbia St. Mary’s.

In the last twelve years, Dr. Janik, along with Charles Koh, M.D., has helped further the use of laparoscopic peritoneal resection and radical excision of endometriosis. In this procedure, the lesions are removed through small incisions (between 5 and 10 millimeters long) in the abdomen. The lesions are excised down to healthy tissue, fully eradicating the existing endometriosis while leaving the organs intact.

Removing the endometriosis and not the unaffected organs is an important distinction. While it is true that endometriosis sometimes grows in the uterus and the adjoining reproductive organs such as the fallopian tubes and ovaries, it also routinely is found in the cul-de-sac (between the vagina and rectum), bladder and bowel. If not removed, these lesions will still react to hormonal cycling.

“The old theory was that the uterus is the source of all endometriosis. Many women had hysterectomies or had their ovaries removed, but the endometriosis was not treated. Their surgeries were ineffective,” Dr. Koh said. “Treatment should not be removal of the surrogate organ (the uterus), but removal of the endometriosis.”

Successful outcomes
Of the 1,000 patients Drs. Janik and Koh have tracked during the last ten years, more than 85 percent report they are still pain-free or pain-controlled after five years.

They also have treated many women who, as a byproduct of their endometriosis, were having trouble conceiving. By removing the endometriosis and, therefore, the toxins it releases into the ovaries and fallopian tubes, the fertility rate of their patients has increased dramatically.

Dr. Janik described that among the most severe cases she and Dr. Koh have treated, the pregnancy rate after laparoscopic surgery was 60 percent (80 percent for those with mild to moderate endometriosis), mostly within the first six months following the procedure. “Many women are pushed too quickly into invitro fertilization. For them, this is a neglected option,” she added.

“Our main focus is on retaining fertility while alleviating pain,” Dr. Janik said of laparoscopic peritoneal resection, emphasizing that patients should not be pressured into a hysterectomy as their only source of pain relief.

“Preservation of the ovaries and uterus are paramount. Any woman who has endometriosis should get a second or third opinion,” Dr. Koh added. “It is incredibly rare to be associated with cancer and not a reason to preemptively remove everything. It is virtually never necessary to remove an ovary in the treatment of endometriosis.”

Diagnosis and treatment options
It should be noted that teenagers are not immune to endometriosis. While symptoms among those under 20 are similar to those encountered by other women (menstrual cramps that get worse over time, pain with bowel movements or when the bladder is full, or pain in the rectal/pelvic region while sitting), they also may experience pain between periods. Another common indicator is when menstrual cramps do not respond to common, over-the-counter pain relievers.

Dr. Janik added that a woman diagnosed with endometriosis and directed by her physician to have a hysterectomy should ask that doctor if he or she specializes in severe endometriosis and is treating it on a more complex level through laparoscopic resection and radical excision. If not, the patient needs to get another recommendation from a doctor specializing in endometriosis.

The same is true for any woman suffering from painful endometriosis that has not responded to cauterization or prescriptions such as Lupron or birth control pills. The way for a woman to identify a specialist center for endometriosis is that it routinely does bowel and ureter resections by laparoscopy without converting to an open incision.

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